Meatal Stenosis

Updated: Sep 22, 2016
  • Author: Joel F Koenig, MD; Chief Editor: Marc Cendron, MD  more...
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Overview

Background

Genital disorders are commonly encountered in the office of the primary care physician. [1] Meatal stenosis is a relatively common acquired condition with a symptomatic presentation that occurs in 9-10% of males who are circumcised; the frequency may be as high as 20% after circumcision if the condition is defined as a meatal diameter of less than 5 French. [2]

Meatal stenosis is typically characterized by an upward-deflected, difficult-to-aim urinary stream and, rarely, by dysuria and urgent, frequent, and prolonged urination. Surgical meatotomy or meatoplasty is normally curative.

For patient education resources, see the Men's Health Center, as well as Foreskin Problems and Circumcision.

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Pathophysiology

After circumcision, a child who is not toilet-trained persistently exposes the meatus to urine, which results in inflammation (ammoniac dermatitis) and mechanical trauma as the meatus rubs against a wet diaper. Loss of the delicate epithelial lining of the distal urethra may then result in fusion of the epithelial lining in the ventral meatus, leaving a narrow orifice at the tip of the glans. Because this condition is exceedingly rare in uncircumcised children, circumcision is believed to be the most important causative factor for meatal stenosis.

Balanitis xerotica obliterans (BXO; also referred to as lichen sclerosus) is a less common cause of meatal stenosis, but as many as 20% of boys undergoing circumcision for BXO may require subsequent operative treatment of meatal pathology. [3]

Another hypothetical cause is ischemia due to damage to the frenular artery during circumcision, resulting in poor blood supply to the meatus and subsequent stenosis. In a prospective study of circumcised boys, Van Howe found meatal stenosis in 24 of 239 (7.29%) children older than 3 years; meatal stenosis was the most common complication of circumcision. [1]

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Etiology

In a child who is circumcised, persistent exposure of the meatus to urine and mechanical trauma from rubbing against a wet diaper results in ammoniacal dermatitis, loss of meatal epithelium, and fusion of its ventral edges. This results in a pinpoint orifice at the tip of the glans.

Other causes of meatal stenosis include the following:

  • Previous  hypospadias repair
  • Trauma
  • Prolonged catheterization
  • BXO, an unusual condition that causes a whitish discoloration and dry appearance of the glans [4]

A 10-year retrospective series of boys with BXO at Boston Children's Hospital included 41 patients with a median age of 10.6 years, of whom 85% were aged 8-13 years. [5] The disease process was found to involve the prepuce, the glans, and sometimes the urethra. The most common referral diagnoses included phimosis (52%), balanitis (13%), and buried penis (10%). In 46% of the patients, circumcision was curative; 27% (11 patients) had meatal involvement that was treated by meatotomy and meatoplasty, and 22% required extensive plastic procedures of the penis, including buccal mucosal grafts.

Meatal stenosis occurs in as many as 20% of pediatric patients with BXO. Although BXO is difficult to treat, meatotomy typically produces a durable treatment of the meatal stenosis.

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Epidemiology

Meatal stenosis affects 9-20% of males who are circumcised. Children who are not toilet-trained are more prone to develop meatal stenosis after circumcision because of exposure of the meatus to urine in diapers. Most children who are toilet-trained can verbalize their difficulties during micturition to their caregivers. Meatal stenosis has no racial predilection. The condition can occur in circumcised males independent of ethnicity.

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Prognosis

Meatal stenosis carries no risk of mortality. The prognosis is excellent after surgery: Meatotomy or meatoplasty is typically curative of the misdirection of the urinary stream. Morbidity is limited to the clinical symptoms and complications of surgical repair, including bleeding, infection, and recurrence. If there are also voiding symptoms (eg, pain with urination or hesitancy), these may be related to underlying voiding dysfunction, and surgical correction of meatal stenosis may not alleviate them.

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